WASHINGTON (AP) - Hospitals, doctors and consumer groups mounted intensifying opposition to the Republican health care bill as GOP leaders labored Wednesday to rally a divided party behind their high-stakes overhaul drive. Lawmakers cast Congress' initial votes on the legislation as House Speaker Paul Ryan praised the proposal as "what good, conservative health care reform looks like."
The American Medical Association, the American Hospital Association and AARP, the nation's largest advocacy group for older people, were arrayed against the GOP measure. Seven years ago their backing was instrumental in enacting President Barack Obama's health care statute, which President Donald Trump and congressional Republicans are intent on erasing.
The hospitals -- major employers in many districts -- wrote lawmakers complaining about the bill's cuts in Medicaid and other programs and said more uninsured Americans seem likely, adding, "We ask Congress to protect our patients." Groups representing public, children's, Catholic and other hospitals also expressed opposition.
America's Health Insurance Plans, representing insurers, praised GOP provisions like erasing health industry taxes but warned that proposed Medicaid changes "could result in unnecessary disruptions in the coverage and care beneficiaries depend on."
In epic sessions that stretched past midnight into Thursday morning, leaders began pushing the legislation toward passage by two House committees -- Ways and Means, and Energy and Commerce.
GOP leaders faced rebellion within their own ranks, including from conservative lawmakers and outside conservative groups. Top Republicans knew if the upheaval should snowball and crush the legislation it would be a shattering defeat for Trump and the GOP, so leaders hoped approval by both House committees would give them momentum.
In words aimed at recalcitrant colleagues, Ryan, R-Wis., told reporters: "This is what good, conservative health care reform looks like. It is bold and it is long overdue, and it is us fulfilling our promises." The last was a nod to campaign pledges by Trump and many GOP congressional candidates.
Outnumbered Democrats used the panels' meetings for political messaging, futilely offering amendments aimed at preventing the bill from raising deficits, kicking people off coverage or boosting consumers' out-of-pocket costs. They tried unsuccessfully to insert language pressuring President Donald Trump to release his income tax returns, and failed to prevent Republicans from restoring insurance companies' tax deductions for executive salaries above $500,000 -- a break Obama's law killed.
There were signs of growing White House engagement, and perhaps progress.
Trump met at the White House late Wednesday with leaders of six conservative groups that have opposed the GOP legislation, and several voiced optimism afterward.
"I'm encouraged that the president indicated they're pushing to make changes in the bill," said David McIntosh, head of the Club for Growth, though he provided no specifics.
Underscoring Trump's potential impact, Energy and Commerce Chairman Greg Walden, R-Ore., said of GOP holdouts, "A lot of them, they maybe haven't felt the inertia that comes with Air Force One landing in their district."
The legislation would defang Obama's requirement that everyone buy insurance -- a provision deeply disliked by Republicans -- by repealing the tax fines imposed on those who don't. That penalty has been a stick aimed at pressing healthy people to purchase policies. The bill would replace income-based subsidies Obama provided with tax credits based more on age, and insurers would charge higher premiums for customers who drop coverage for over two months
The extra billions Washington has sent states to expand the federal-state Medicaid program would begin ending in 2020, and spending on the entire program would be capped at per-patient limits. Around $600 billion in 10-year tax boosts that Obama's statute imposed on wealthy Americans and others to finance his overhaul would be repealed. Insurers could charge older customers five times more than younger ones instead of the current 3-1 limit, but would still be required to include children up to age 26 in family policies, and they would be barred from imposing annual or lifetime benefit caps.
"We will answer President Trump's call to action," said Ways and Means Chairman Kevin Brady, R-Texas, adding later, "Relief is on the way."
Democrats said the Republicans would yank health coverage from many of the 20 million Americans who gained it under Obama's statute, and drive up costs for others because the GOP tax breaks would be skimpier than existing subsidies. And they accused Republicans of hiding bad news by moving ahead without official estimates from the nonpartisan Congressional Budget Office on the bill's cost to taxpayers and anticipated coverage.
"The bill sabotages the marketplaces where close to 10 million Americans today get coverage and starts a death spiral from which we will never recover," said Ways and Means' top Democrat, Richard Neal of Massachusetts.
On the Republican side, conservatives in particular were up in arms, saying the tax credits would be too expensive and the phase-out of Obama's Medicaid expansion too slow. One conservative group, FreedomWorks, was launching digital and social media ads opposing the legislation, while others like Americans for Prosperity, backed by the wealthy Koch brothers, were working against the legislation.
Numerous GOP centrists and governors were also antagonistic, worried their states could lose Medicaid payments and face higher costs for hospitals having to treat growing numbers of uninsured people.
At first glance, the new health care bill from House Republicans appears to have similarities to the Obama-era law, like tax credits, protections for people with health problems, and the ability of parents to keep young adults on their insurance.
But in most cases those components would work very differently under the GOP framework than is currently the case with the Affordable Care Act, or Obamacare.
Key details about the Republican plan are still unknown, including cost and coverage. Here's a comparison between Obama's ACA, which is current law, and the GOP's bill:
Current law: About 11 million people are covered by expanded Medicaid in the 31 states that accepted it. Nationwide another 12 million buy private health insurance through government-sponsored markets that offer plans with subsidized premiums. The national uninsured rate is below 9 percent, a historic low.
GOP bill: Extent of coverage is unknown at this time, as well as its impact on the nation's uninsured rate.
Current law: Coverage costs of about $1.4 trillion from 2017-2026, based on Congressional Budget Office estimates.
GOP bill: Unknown at this time; Republican aides say CBO numbers are coming shortly.
Current law: States that accept expanded Medicaid receive a generous federal match, gradually phasing down to 90 percent. The expansion covers people with incomes up to 138 percent of the federal poverty line, or about $16,640 for an individual. Most new beneficiaries are low-income adults with no children living at home.
More broadly, Medicaid is now the country's largest health insurance program, covering more than 70 million people under a federal-state collaboration. It remains an open-ended entitlement, allowing states to draw down federal money for a portion of health costs incurred by low-income people, from children to nursing home residents.
GOP bill: Ends the higher federal match for Medicaid expansion beneficiaries, starting in 2020. States can still continue to receive some enhanced federal payments, but only for expansion enrollees who were already covered before that. States will get a lower match for new enrollees.
But more significantly, the bill would overhaul the framework of Medicaid, ending its open-ended federal financing. Starting with the 2020 fiscal year, each state would receive a limited, per-beneficiary amount based on enrollment and costs. States would gain flexibility to cap enrollment and change benefits. Federal payments would be increased according to a measure of medical inflation. Impacts are unclear.
PRIVATE COVERAGE FOR INDIVIDUALS
Current law: Provides income-based tax credits for consumers buying government-regulated plans through HealthCare.gov and state insurance markets. The most generous assistance goes to people with low-to-modest incomes. Many solid middle-class households get no help despite sharp increases in premiums.
GOP bill: Provides tax credits primarily based on age, gradually phasing down for individuals making over $75,000, or married couples earning more than $150,000. Credits can be used to buy any state-licensed health plan. More middle-class consumers will benefit, but there's concern lower-income people would be disadvantaged.
Current law: Provides cost-sharing subsidies for low-to-moderate income people who buy a standard silver plan in the government markets.
GOP bill: Eliminates ACA's cost-sharing subsidies, but allows people to make much higher contributions to tax-sheltered health savings accounts, to cover deductibles and copayments. Sets up a fund that states can use for a variety of purposes, including cost-sharing assistance.
Current law: Forbids insurers from turning people down on account of medical problems, or charging them more.
GOP bill: Provides protection for people with health problems. But consumers who have not maintained continuous insurance coverage face a 30 percent premium penalty for a year. States can use federal funds to set up high-risk pools as insurers of last result.
Current law: Insurers can charge their oldest customers no more than 3 times what they charge young adults. That benefits older adults prone to illness but has made coverage costly for young people.
GOP bill: Insurers could charge older customers up to 5 times what they charge young adults. Advocates for older people complain that's unfair.
Current law: Can stay on parental insurance until age 26.
GOP bill: Same.